Objective: This study examines' demographics, clinical
characteristics and drinking patterns of students presenting with
alcohol intoxication at a university health service. Participants: The
sample included one hundred students (50% female, 48% freshmen) treated
for alcohol intoxication at university student health services. Complete
medical charts were obtained for 80 students (43% female, 46% freshmen).
Methods: A prospective case review was performed between September 2005
and March 2006. Results: Although males reported having more drinks
before admission, drinking more frequently, and having more drinks per
drinking day than females, there were no other gender differences.
Freshmen comprised almost half the admissions, but there were no
significant differences in drinking patterns across school years'.
While only 54% of students were given follow-up referrals, 72.2% of
students complied with recommended referrals. Additional assessment
information included alcohol use disorders sceening scores, history of
previous alcohol intoxication, problems related to use, symptoms of
anxiety and depression, and use of antidepressant medication.
Conclusions." These results suggest that further investigations of
student characteristics and experiences prior to contact with university
health services are warranted and may be necessary to the development
and implementation of programs to reduce harmful alcohol consumption.

**********

Rates of binge drinking among college students (five or more drinks
per occasion for men and four or more drinks per occasion for women)
have remained relatively stable: Approximately forty-four percent of all
college students report binge drinking over the course of a school year,
with roughly half reporting occasional binge drinking and half reporting
frequent binge drinking (Wechsler et al., 2002). The Monitoring the
Future project that took place in 2005 reported similar findings. The
majority (83.0%) of full-time college students reported consuming
alcohol within the last year, and 40.1% of students reported drinking
five or more alcoholic beverages in a row in the past two weeks
(Johnston, O'Malley, Bachman, & Schulenberg, 2006).
Additionally, college students reported a significantly greater number
of heavy drinking episodes than their same-age peers not enrolled in
college. College students were also more likely to confine their
drinking to a limited number of days per week but drink in greater
quantities during those days compared to non-students their ages
(Johnston, O'Malley, Bachman, & Schulenberg, 2006).

Binge drinking by college students has been associated with
numerous negative long-term and short-term consequences including
increased incidence of health problems, risk of unintentional injury,
poor academic performance, and driving under the influence (Barnett et
al., 2003; Cherpitel, 1993; Wechsler et al., 2002). In addition,
students who binge drink are at an increased risk for date rape, sexual
assault, engaging in unwanted sexual activity, and not using adequate
protection against pregnancy and sexually transmitted diseases while
intoxicated (Wechsler, Lee, Kuo, & Lee, 2000; Wechsler et al.,
2002). Furthermore, consequences of heavy episodic or binge drinking are
not limited to drinkers themselves, but may also result in negative
consequences, or "secondhand effects," for non-drinking
college students. For example, students report unwanted sexual advances,
engagement in physical or verbal fights, and study or sleep interruption as a result of binge drinkers' behaviors (Turner & Shu, 2004).

The use of emergency medical treatment following severe
intoxication among college students has been documented by previous
research (Barnett et al., 2003; Helmkamp et al., 2003; Wright, Norton,
Dake, Pinkston, & Slovis, 1999; Wright & Slovis, 1996); however,
fewer studies have focused on the reasons why some college students
consume enough alcohol to require medical attention. While the use of
alcohol by college students is widespread, and roughly half of these
drinkers report binge drinking, far fewer receive medical care following
acute intoxication (Helmkamp et al., 2003; Wright & Slovis, 1996).
This suggests that students presenting for urgent treatment with acute
alcohol intoxication may be a unique subgroup; however, little is known
regarding how these individuals may differ from their binge drinking
peers who do not seek medical care.

Previous studies have reported similar rates for males and females
receiving treatment for alcohol-related emergencies as well as a greater
frequency of admissions for college freshmen (Barnett et al., 2003;
Wright, Norton, Dake, Pinkston, & Slovis, 1999; Wright & Slovis,
1996). Wright and Slovis (1996) reviewed admissions of college students
to a university hospital emergency department and found an overall
incidence of 3.9 students per 1,000 per year requiring medical treatment
for alcohol intoxication. This rate was almost 2 1/2 times greater for
first year students who had an incidence of 9.3 per 1,000 students per
year. However, they found no significant difference between proportions
of males and females who presented for treatment (Wright & Slovis,
1996). In another recent study, Reis and colleagues (2004) interviewed
50 first-year college students after transport for medical care
following alcohol intoxication. In general, these first year students
did not view themselves as being at risk for alcohol overdose before the
overdose event, and stated that the event was due to bad decision making
rather than a typical pattern of heavy drinking (Reis, Harned, &
Riley, 2004).

While prior research has addressed characteristics of college
students treated at Emergency Departments (EDs) for alcohol
intoxication, research has generally not adequately addressed
utilization of university health services among college students for
both acute alcohol-related problems as well as for follow-up
interventions. The aims of the current study were to (1) examine
characteristics of students treated at university health services
following alcohol intoxication, and (2) explore the rate of compliance
with the recommendation to seek further evaluation among students
referred for follow-up.

Based on existing literature, we hypothesized that males and
females would present for acute alcohol treatment to university health
services at similar rates, but that drinking patterns (especially rates
of binge drinking) would differ significantly by gender. We also
hypothesized that freshmen students would be more likely than those in
upperclasses to seek treatment for alcohol intoxication. In addition, we
explored other characteristics of these students including their CRAFFT scores (an acronym mnemonically based on key words of the 6-question
alcohol screening test, Knight et al., 1999), symptoms of anxiety and
depression, previous history of admissions for alcohol intoxication,
history of alcohol consumption, and other alcohol related problems.
Finally, we analyzed the rate at which follow-up appointments were made
and the rate of compliance among students who were referred for
follow-up.

METHODS

A review of the medical records of consecutive admissions for
alcohol intoxication to University Health Services (UHS) After Hours Urgent Care Center was performed between September 1, 2005 and March 12,
2006. IRB approval was obtained from both McLean Hospital and Harvard
University. The urgent care center provides 24-hour care for the
university community. Students presented for treatment to UHS by
self-referral, referral by a concerned friend, or referral by university
personnel (e.g., residential life staff or university police). Students
who were agitated or were so intoxicated that they required closer
monitoring were sent to a local emergency department for stabilization,
but were typically transferred to UHS prior to returning to campus.

As a part of the UHS evaluation, nurses administered an alcohol
assessment questionnaire that included the CRAFFT questions which were
developed to screen for alcohol dependence in the adolescent population
(Knight, Sherritt, Harris, Gates, & Chang, 2003; Knight et al.,
1999), selected questions from the Alcohol Use Disorders Identification
Test (AUDIT) screening tool (Saunders, Aasland, Babor, de la Fuente,
& et al., 1993), and questions screening for symptoms of depression
and anxiety. Knight and colleagues (2003) reported that a score of two
or more positive answers on the CRAFFT questionnaire indicates a need
for intensive treatment, and a score of 1 positive answer warrants
further evaluation. Several studies have demonstrated that the
instrument has high sensitivity and specificity for treatment need as
well as identification of alcohol use disorders (Knight, Sherritt,
Harris, Gates, & Chang, 2003; Knight, Sherritt, Shrier, Harris,
& Chang, 2002; Knight et al., 1999) The AUDIT questions included in
the measure were "How many drinks of alcohol do you have on a
typical day when you're drinking?" and "How often do you
have 5 or more drinks at one sitting (4 for women)?"

Follow-up care for students admitted for alcohol intoxication is
provided at UHS by the student's primary care doctor. In certain
cases, an additional appointment is made for the student with a
clinician in Mental Health Services or with the director of Alcohol and
Substance Abuse Services for educational programming. Specific follow-up
care plans for students in this study were recommended on a case-by-case
basis by the UHS physician who saw the students in the urgent care
center prior to discharge. At the time of this study, there was no
standard procedure for recommending follow-up medical care or mandated
administrative sanctions for these students.

Statistical Analysis

To compare gender and year in school by background variables,
chi-square analyses were used for categorical variables and independent
t-tests for continuous variables. Number of drinks prior to admission,
drinks per typical drinking day, and frequency of binge drinking
(defined as 5 drinks in one sitting for males and 4 for women) were
examined using independent t-tests. Total CRAFFT scores were also
examined using independent t-tests. Finally, chi-square analyses were
used to investigate differences in early semester admissions (defined as
admission to UHS during the months of September and October) between
freshmen and other upperclassmen and between females and males. All
analyses used SPSS 14.0 for Windows.

RESULTS

Sample

One hundred (50.0% female) students were admitted to the university
after hours acute care service for alcohol intoxication during the study
period. Complete charts were obtained from 80 (53.8% females) students.
Table 1 presents the characteristics of the entire sample. The mean age
for all students was 19.32 ([+ or -] 1.78). The majority of students
(78.0%) were below the legal drinking age. Forty-eight percent of
students admitted for alcohol intoxication were freshmen, 22.0% were
sophomores, 11.0% were juniors, 14.0% were seniors, and 5.0% were
graduate students. The majority of students admitted were white (59.3%).
There were no significant gender differences across background variables
(Table 1). Differences in background variables across school year were
significant only for age. Five students required transfer to an ED for
additional treatment after presenting to UHS. An additional 30 students
were sent directly to an ED without first being seen at UHS. On
discharge from the ED, the university requested that students be
transferred to UHS for clearance prior to discharge back to their
residences.

Gender differences in drinking characteristics and year in school

The mean ([+ or -] SD) drinks prior to admission for all students
with complete charts was 8.06 ([+ or -] 5.07). Females reported drinking
significantly less than males prior to admission to UHS (t (28.43) =
3.38,p <.01). Women also reported having fewer drinks per typical
drinking day (t (76) = 3.45,p <.001) compared to men. In fact, 4.8%
of females compared to 25.0% of males reported drinking at least 7
standard drinks on a typical drinking day. Females also reported lower
binge drinking frequency than males, with 67.4% of females and 97.3% of
males reporting ever having at least one episode of binge drinking (t
(78) = -3.67, p < .001). 14 (32.5%) females compared to only one male
(3.7%) reported never binge drinking (see Table 1).

Year in School Differences by Month of Admission and Other
Characteristics

There was a significant difference in month of admission between
freshmen and upper-class students (Figure 1). Freshmen were
significantly more likely than upper-class students to be admitted in
the first two months of the year (55.8%, p < .05). Furthermore,
freshmen were significantly more likely to be admitted in the first two
months than later in the academic year (60%, p < .05). There was no
significant difference between males and females in month of admission.
In fact, males and females were equally likely to have been admitted
early in the semester (50.0% females admitted during September and
October). Although freshmen were overrepresented in our sample, there
were no significant differences between freshmen and upper-class
students in the overall mean drinks prior to admission to UHS, mean
drinks per drinking day, frequency of binge drinking, or CRAFFT scores.

Drinking Histories and Symptoms of Anxiety and Depression

Of the students with complete medical records, twenty-five (31.3%)
reported experiencing anxiety in the two weeks prior to admission,
eighteen (22.5%) endorsed one or more symptoms of depression in the
preceding two weeks, one reported having "thoughts of harming self
or recurrent thoughts of death," and eight (10.0%) reported taking
antidepressant medications. Of all students admitted to UHS, twenty-nine
(29.0%) had been previously seen by UHS mental health services and six
(6.0%) had a documented history of alcohol related problems. Ten
students (10.0%) were admitted to urgent care more than once for alcohol
intoxication.

The mean CRAFFT score for students with complete charts was 1.44
([+ or -]1.32). The range of CRAFFT scores in our sample was 0-5, with
26 students (32.5%) endorsing two or more criteria. The most frequently
reported CRAFFT item was forgetting things done under the influence,
which was endorsed by 48 students (60.0%). Twenty-four students (30.4%)
reported doing something while intoxicated that they would not have done
otherwise. CRAFFT scores and anxiety and depression symptoms did not
differ significantly between male and female students.

Adherence to Recommendation for Further Evaluation

Students were discharged with a scheduled follow-up appointment in
primary care in 54% of cases. Thirty-nine (72.2%) of these 54 students
followed through with the primary care appointment that was scheduled
for them.

DISCUSSION

As expected, we found an overrepresentation of freshman students
admitted to university health services for alcohol intoxication. These
findings are consistent with previous research demonstrating that
freshmen are more likely to present for alcohol-related medical
treatment compared with their upper-class peers (Wright, Norton, Dake,
Pinkston, & Slovis, 1999; Wright & Slovis, 1996) We also found
that freshmen students were more likely than their upper-class
counterparts to present for treatment within the first two months of
school (Figure 1). This finding may suggest a degree of drinking
inexperience that leads to drinking too much too fast, and this pattern
may differ from that of students admitted with alcohol intoxication
later in the year (Barnett et al., 2003).

As expected, there was no gender difference in the rate of
admission for alcohol intoxication. However, drinking patterns differed
significantly by gender. Female students presented for treatment after
using significantly less alcohol than males in the hours preceding
admission. In our sample, males reported significantly greater numbers
of drinks per typical drinking day and greater frequency of binge
drinking episodes than females. These findings replicate other studies
indicating increased vulnerability of females to the acute effects and
other consequences of drinking at lower doses than their male
counterparts, due in part to differences in physiologic sensitivity and
alcohol metabolism (Ely, Hardy, Longford, & Wadsworth, 1999;
Greenfield et al., 2007). This finding may also reflect gender
differences in perceptions about what is an acceptable level of
intoxication for college women versus men as many referrals were made by
concerned friends. In this study, females reported fewer binge episodes
and drank fewer drinks per occasion, but the number of female admissions
to UHS and their CRAFFT scores were not significantly different from
males.

In our sample, 54% of students were referred for a follow-up
appointment with a primary care physician (PCP), and 10% of these
students were also referred to a mental health clinician or other
counselor for further evaluation of their drinking behaviors. Different
attitudes of urgent care physicians regarding binge drinking may have
contributed to inconsistencies in the recommended follow-up.
Alternatively, physicians may have used their own clinical judgment to
refer only those students for whom the intoxication appeared to be more
than an isolated event. Our sample was too small to capture potential
differences between students who did and did not receive referrals. It
is particularly notable that when primary care follow-up appointments
were made for students at the time of discharge from UHS, the rate of
compliance was high (72.2%). This finding is encouraging given previous
data about college students' low rates of follow-up with
recommended alcohol evaluation following routine screening (Greenfield
et al., 2003). In a follow-up study of National Alcohol Screening Day,
Greenfield and colleagues (2003) found that only 20% of college student
participants followed through with recommended additional evaluation
compared with 50% of non-college community participants.

However, students that have had a specific incident, such as one
that resulted in evaluation at UHS, may be more motivated to comply with
recommended follow-up than students in a routine screening setting. This
higher rate of compliance with follow-up recommendations in the setting
of acute alcohol intoxication is consistent with studies in other
populations treated in emergency room settings (Helmkamp et al., 2003).
It is possible that follow-up appointments with a primary care physician
are perceived by students as less stigmatizing. In addition, students
may be more likely to participate in follow-up that does not involve a
commitment to multiple visits. This finding is also encouraging given
that students are likely to benefit from even a single follow-up meeting
when motivational enhancement techniques are employed. Other research
has demonstrated that students who presented to an ED for treatment
responded well to brief interventions (Ehrlich, Haque, Swisher-McClure,
& Helmkamp, 2006; Helmkamp et al., 2003). Therefore, student health
services may be a venue where a motivational interviewing approach may
be especially useful.

Our study indicates that routine referral by university health
services in the setting of acute intoxication can provide an opportunity
for education and intervention in the college population. Since this
data were gathered, the university health services implemented a new
procedure in which all UHS students who present for treatment of alcohol
intoxication are provided a follow-up appointment with their PCP and
invited to meet with the director of Alcohol and Substance Abuse
Services. This decision is no longer left to the discretion of the
discharging clinician. Together, our results suggest that scheduling an
appointment with the student prior to discharge is likely to improve
compliance with recommended follow-up, and incorporating motivational
interviewing techniques may further enhance the effectiveness of this
intervention.

Our study provides preliminary evidence for certain subgroups of
students who present with alcohol intoxication. Many of the students in
our sample endorsed symptoms of anxiety or depression prior to their
most recent drinking episode; however, despite the fact that nearly one
third had previously been seen in mental health, few had been formally
diagnosed with a mood or anxiety disorder. While we did not have data
regarding the proportion of these students who were engaged in ongoing
counseling or behavioral treatment, very few of these students reported
receiving pharmacologic treatment for anxiety or depression. Previous
work has suggested that most college students drink for social reasons
rather than to "self-medicate" for psychiatric symptoms
(Reifman & Watson, 2003). However, students with anxiety and
depression report that their psychiatric symptoms often pre-date their
alcohol related problems (Ross & Tisdall, 1994). Research has also
found that students with higher levels of anxiety and depression
indicate greater readiness to change drinking behaviors, perhaps due
their self reflection regarding the consequences of drinking (Smith
& Tran, 2007). Therefore, our results suggest a need for ongoing
screening and treatment for these conditions in the college population,
particularly in students with problematic drinking patterns.

A small number of students in our sample had been previously
identified as having alcohol use problems, and 10% of students presented
to UHS with intoxication more than once. It is possible that these
students represent a sub-group with more significant alcohol problems
that require a more intensive level of intervention. In addition, 35% of
students in our sample required treatment at a local ED for medical
stabilization due to their degree of intoxication. Our sample size was
too small to capture whether this sub-group may also differ from the
larger population in drinking patterns, consequences of use, or other
clinical characteristics. One third of our sample endorsed two or more
CRAFFT criteria, thus crossing the previously defined threshold
suggestive of an alcohol problem needing intensive treatment. In
addition, nearly one fourth of the students reported having done
something while intoxicated that they would not have otherwise done and
sixty percent reported blackouts or forgetting things done while
intoxicated. It is possible that students reporting these negative
consequences of drinking carry a different level of risk for future
problems than their counterparts for whom a single presentation for the
treatment of alcohol intoxication represents an isolated incident.
Students who report some negative consequences related to their drinking
also represent a group that may be quite amenable to brief motivational
enhancement interventions. Longitudinal studies explicating the course
of student's drinking behaviors and exploring the relationship of
other variables such as anxiety and depression will be necessary to
better serve this population.

Our study design limits the generalizability of our results in
several important ways. The sample consisted primarily of White and
non-Hispanic young adults. Also, these results are based on a
convenience sample of students seeking treatment for alcohol
intoxication in one student health services' urgent care setting.
Since only students admitted for treatment of acute intoxication
completed the alcohol use questionnaire, we have no comparison of
drinking patterns and binge drinking rates with other non-treatment
seeking university students. Information about family history of alcohol
use disorders or psychiatric illness was not available for the majority
of students in our sample. Given the association between family history
and development of alcohol use disorders, this is an important measure
of potential risk. University health centers should be encouraged to
gather both general information about students' patterns of alcohol
and other drug use as well as family history of addictive disorders as a
part of routine evaluation of college students, and in particular those
who present for treatment of intoxication.

In spite of these limitations, this study contributes new
information regarding characteristics of college students presenting for
medical treatment for alcohol intoxication and their rates of follow-up
with recommendations for further evaluation. In addition, our results
suggest that university health services can provide a critical venue for
alcohol education and intervention, and that targeting freshman early in
their first semester of college may be especially warranted. Screening
and brief interventions have been noted to be successful in many
populations (Ehrlich, Haque, Swisher-McClure, & Helmkamp, 2006;
Helmkamp et al., 2003). The university urgent care service can have an
important role delivering these interventions to the significant
minority of students most at risk for developing alcohol use disorders:
those presenting with threshold screening scores, specific negative
consequences of their drinking such as blackouts or unwanted behaviors
while intoxicated, as well as histories of depressive or anxiety
symptoms that preceded the drinking episode requiring evaluation.
Finally, more research is necessary to demonstrate the most effective
means to provide prevention of binge and problematic alcohol use
especially before or within the first semester.